Featured Cases

Our Featured Cases are just a few examples of the many kinds of concerns that people can bring to our office. To read more examples, see our list of Featured Cases. For more information about what we do, or to contact us, see the "Make a Complaint" page.

The names of complainants have been changed to protect their identity.

 

Blood Tests, Re-tests and Results

Carl contacted our office because he believed that the Saskatchewan Disease Control Laboratory (SDCL) had lost his bloodwork three times over the course of eleven years. He was particularly concerned about this because he had been diagnosed with Hepatitis C and believed he may have gone untreated for several years. After undergoing some treatments, a negative test result led him to question the initial results. He began to wonder if he had been incorrectly diagnosed as well.

Our investigation found that, in the first instance, his blood tested positive for Hepatitis C and the lab sent the results to the doctor who ordered the blood test. We do not know what attempts the doctor made to contact Carl, since doctors are responsible to the College of Physicians and Surgeons. We did find that the lab also sent the results to Public Health Services, which made three attempts to contact Carl at the address they had on file for him. They were unsuccessful in contacting him.

In the second instance, the blood test was again positive for Hepatitis C and the lab sent the results to the doctor (not the same doctor who made the first request). Since this was a re-test, the policy only required that the information be sent to the doctor. We believed there was a legal obligation – and it would be a best practice – to consistently track and  communicate all tests and re-tests related to reportable communicable diseases.

Some years later, Carl was tested by yet another doctor, learned his diagnosis, and that he had been Hepatitis C positive when he had been tested years prior. He took some treatments. Following this, he was tested again and the test came back with negative results. Carl began to question the positive previous tests – but they had been correct.

Sometime after this, Carl’s doctor requested blood work again. Two vials of blood were taken at the hospital: one for a set of tests that could be done there, and a second which was to have been sent to the SDCL for further screening. SDCL said it never received the vial. The health region had conducted an internal investigation and provided Carl with their findings and an apology.

We explained to Carl what happened with each of his blood tests and provided our recommendations to the Ministry of Health.

Recommendations

  1. That the Ministry ensure that the Saskatchewan Disease Control Laboratory report all tests (first and any additional re-tests) that find or confirm a reportable communicable disease to the appropriate medical health officer.

    Status: Accepted


  2. That the Ministry of Health, in consultation with the health regions,create a consistent reporting and tracking process as it relates to reportable communicable diseases throughout the province. This would include the reporting and tracking of all first tests and re-tests.

    Status: Accepted


  3. That the Ministry of Health implement recommendation 13 of the Patient First Commissioner’s Report which is as follows:

    That the Ministry of Health, in consultation with the health regions, the Cancer Agency,and clinical  leaders, invest in and accelerate the development of provincial information technology (IT) capabilities within a provincial framework. This will involve:

    a. Developing an e-Health implementation plan by early 2010;

    b. Securing and stabilizing funding for both the provincial electronic health records  requirements and health region implementation requirements; and

    c. Determining the preferred service delivery structure for IT at the health region level to ensure the realization of one provincial system.


    Status: Accepted
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